Permanent Makeup for Breast Reduction Scars, Eyebrow Hair Loss and Much More

2. Are you on any medications? If so, e-mail me a list of medication.

3. Are you using blood thinners, aspirin, steroids, acutane...?

4. Have you had a cold sore in the past? (If so we suggest using Valtrex 1 week before and one week after procedure)

5. Have you had any eye surgery?

6. Are you allergic to any food or medication? This includes antibiotics ointments and Latex . If so, e-mail me the details

7. Do you have any blood diseases?

8. Do you use Retin A? If so discontinue two weeks before until procedure heals.

9. What procedures are you interested in?

10. Do you want a patch Test (this is required for scar/ breast camouflage only)?

11. May I use your Photo?

12. I understand that I have read the nature of my Permanent Cosmetics Treatment, and the risks. I consent to Cheryl Rosenblum/Nishawne Hinds performing the procedure. Being of sound mind and body, I hereby release Cheryl Rosenblum/Nishawne Hinds and accept responsibility for myself.

13. I have read and understand the aftercare requirements.

14. I am over the age of 18.

15. If I have any type of allergic reaction I will contact my doctor ASAP, and notify Cheryl Steinberg.

16. Are you pregnant?

17. What Type of Payment form will you be using?

Note: We do not accept credit/debit cards

18. Do you have "Mitral Valve Prolapse." If so you will need to inform your Doctor and get proper medication.

19. Do you plan on having laser done on your face. If so have your doctor cover the tattooed area.

20. How did you hear about me?

21. I understand not to get collagen after full lip procedure.

22. I understand not to put anything on tattooed area for at least 10 days.

23. I understand to only use the shea butter given and nothing else, and that if I use anything else I may have complications (i.e.: cold sores, blisters, color loss, blotchy color, swollen eyes, allergic reaction...)

24. I will e-mail phone number and person to contact in case of an emergency.

		Contact Name:
		Contact Phone:

25. Have you had other tattoo?

26. Do you Keloid?

27. I understand that I need to print out this form and bring the history form to my first appointment.

28. I understand that there is a risk of an eye infection if the eye area is not kept clean (keep shea butter out of the eye area use only in the lash line). There also is a slight risk of a abrasion on the Cornea in eyeliner procedures. Abrasions can be caused by rubbing or wiping the eye after the procedure when the eye is still numb. If the eye area is scratchy or gooey I understand to call Cheryl ASAP and a recommended Doctor. Both problems require eye drops and heal quickly but there may be a loss of color in the case of an eye infection. The risk is about a 8% chance of a slight eye infection and a 1% chance of an abrasion.

29. I understand that several touchups may be required and that all skin takes the ink and color different. Color needs to be checked at least once a year. I also understand there are no refunds on permanent makeup procedures.

30. For hair simulation clients. I understand that desired results can take a few sessions. If I shade my hair a dark color, I need to keep that dark color or the shading may not look natural. i.e. Hair shading may fade, and touchups may be required. I have read the after care instruction.